Headache Flashcards
HA
Primary vs Secondary
Primary: Migraine (with or without aura), Tension, Cluster
-No known underlying cause
-90% of headaches are benign primary type
Secondary Headache: Brain tumors, aneurysms
-Symptoms of underlying disorder
Migraine
general
Common disorder
Women > Men
Boys < Girls (< 12yo more often seen in boys) -Increased with age, Abdominal migraines
Age 30-39
Though possible from child to elderly
Very old and very young uncommon
Familial/genetic component
Major cause of disability worldwide
Migraine
patho
Still developing theory
Genetic component – hyperexcited neurovascular system
Cortical spreading depression
Trigeminal nerve activation
Intracerebral vasodilation component
Migraine
S/Sx
Episodic disorder
Lasting minutes to days
Unilateral, usually
Retro-orbital
Pulsating
Photophobia / Phonophobia
Associated with nausea and vomiting
May be associated with aura
No persistent, hard neurological findings
Migraines classifications
Classic vs common
Migraine with aura (classic migraine)
Less common
Migraine without aura (common migraine)
More common by 5:1
migraine
prodome
Yawning, euphoria, fatigue/depression, irritably, food cravings
Migraine
Aura
Aura is defined as a focal visual, sensory, or motor neurologic disturbance with a developing headache
Can include bright lines, shapes, tinnitus, noises, paresthesia, loss of vision, hearing, feeling or ability to move a part of the body
Increases in intensity over one to several hours, often unilateral, throbbing or pulsatile in quality
Common to report photophobia, phonophobia and cutaneous allodynia (perception of pain caused by normal activities i.e., wearing glasses)
Associated with ~25% of migraines (classic migraine)
Migarine
headache
Usually Unilateral throbbing, nausea, vomiting, photophobia, phonophobia
migraine
Scintillating scotoma
Scintillating scotoma – Aura spots that flicker between light and dark
HA
PE to do’s
Obtain blood pressure and pulse
Listen for bruits for clinical signs of arteriovenous malformation
Palpate the head, neck, and shoulder regions
Check temporal and neck arteries
Examine the spine and neck muscles
The neurologic examination should cover mental status testing, cranial nerve examination, funduscopy and otoscopy, and symmetry on motor, reflex, cerebellar (coordination), and sensory tests.
Gait examination should include getting up from a seated position without any support and walking on tiptoes and heels, tandem gait, and Romberg test.
Migraines
Dx
clinical
Migraine
criteria (w/o aura)
●(A) At least five attacks fulfilling criteria B through D
●(B) Headache attacks lasting 4 to 72 hours (untreated or unsuccessfully treated)
●(C) Headache has at least two of the following characteristics:
*Unilateral location
*Pulsating quality
*Moderate or severe pain intensity
*Aggravation by or causing avoidance of routine physical activity (eg, walking or climbing stairs)
●(D) During headache, at least one of the following:
*Nausea, vomiting, or both
*Photophobia and phonophobia
●(E) Not better accounted for by another ICHD-3 diagnosis
criteria for migraine with aura
● At least two attacks fulfilling criterion B and C
● One or more of the following fully reversible aura symptoms:
*Visual
*Sensory
*Speech and/or language
*Motor
*Brainstem
*Retinal
●(C) At least three of the following six characteristics:
*At least one aura symptom spreads gradually over ≥5 minutes
*Two or more symptoms occur in succession
*Each individual aura symptom lasts 5 to 60 minutes
*At least one aura symptom is unilateral
*At least one aura symptom is positive
*The aura is accompanied, or followed within 60 minutes, by headache
●(D) Not better accounted for by another ICHD-3 diagnosis
migraine
abortive Tx
- Nonpharmacologic/avoidance of triggers
-
NSAID & APAP
Ketorolac -
Triptans
Sumatriptan (Imitrex)
Rizatriptan (Maxalt) - Ergotamine
- Dopamine antagonist & Diphenhydramine
Metoclopramide (Reglan)
Prochlorperazine
Chlorpromazine (Thorazine) - Steroids
- Fluids
- Opioids
migraine
preventative medications
Topiramate (Topamax)
Valproate (Depakote)
Propranolol (Inderal)
Non-pharmacological/avoidance of triggers
Migraine
Special population Tx
Pregnant
Avoid ergotamine & NSAIDs
Antiepileptics NOT approved for migraine use
ACOG recommends Reglan (B) and Acetaminophen
< 12 yo – pediatric population considerations
Avoid Triptans
NSAIDs & APAP
Promethazine (Phenergan)
Propranolol for preventative
Tension headache
general
Most common type of headache
Bilateral, band or vice like
Pericranial muscle involvement
Nuchal rigidity?
No hard neurological findings
Tension HA
Classifications based on frequency
Infrequent episodic
< 1 per month
Frequent episodic
1-14 per month
Chronic
> 14 per month
Tension HA
EPI
- Most common type of primary headache
- Universal, 86% of 12-41yo
W > M, slightly - 2-3 times more common in kids as opposed to migraines
Increases with age and is also higher in female kids
Presentation similar to adults - Most people can identify a cause:
Stress, fatigue, eye strain, myalgias, mild viral infections
Tension HA
features
Mild to moderate pain
Non-throbbing
Dull, pressure, band, tight hat
Pericranial muscle tenderness
No other associated features
tension
Dx
clinical
At least two of following:
Bilateral
Pressing or tight quality
Mild to moderate intensity
Not aggravated by routine physical activity
And, both of following:
No nausea or vomiting
No more than one of photophobia or phonophobia